Chapter 20, Health History and Physical Assessment

A nurse observed that a patient's nails have a large angle and a softening of the nail bed. Which condition would the nurse suspect in this patient? 1. Anemia 2. Trichinosis 3. Chronic hypoxia 4. Subacute bacterial endocarditis

Correct 3. Chronic hypoxia A large angle and softening of the nail beds are signs of a chronic deoxygenation problem. In chronic deoxygenation, the angle between the nail and the nail base eventually grows to larger than 180 degrees. The nail bed become soft, nails are flattened, and enlargement of the fingertips occur. In anemia, the nails appear like concave curves. In trichinosis and subacute bacterial endocarditis, red or brown linear streaks appear in the nail bed.

A nurse assesses a patient who presents with a cough. Which position should the nurse instruct the patient to assume for a proper examination? 1. Sims 2. Prone 3. Sitting 4. Supine

Correct 3. Sitting The nurse should ask the patient to assume a sitting position. The upright position provides better visualization of the symmetry of the upper body, thorax, and lungs. The Sims position is used to examine the rectum and vagina. The prone position is used to examine the musculoskeletal system. The supine position is used to examine the head and neck, breasts, axillae, heart, abdomen, extremities, and pulse.

During the physical examination of a patient, the nurse listens to the heart sounds to detect variations from normal. Which physical examination technique is the nurse performing? 1. Palpation 2. Inspection 3. Percussion 4. Auscultation

Correct 4. Auscultation The nurse performs auscultation. Auscultation involves listening to the sounds of the body to detect abnormalities. Palpation is used to make judgments about abnormal and normal findings of the skin or underlying tissue, muscle, and bones. In the inspection technique, the nurse observes the size, shape, color, symmetry, position, and abnormality of various body parts. Percussion involves tapping the skin with the fingertips to vibrate the underlying tissues and organs.

During the assessment of a patient, the nurse finds purple streaks in the nailbed of the patient's fingers. How should the nurse interpret this assessment finding? 1. The patient has clubbing. 2. The patient has paronychia. 3. The patient has distal digital infarcts. 4. The patient has splinter hemorrhage.

Correct 4. The patient has splinter hemorrhage. Purple or brown streaks on the nailbed indicate splinter hemorrhage in the patient. This occurs as a result of various medical conditions such as trichinosis and subacute bacterial endocarditis. Clubbing is enlargement of the fingertips, softening of the nailbed, and flattening of the nail; there are no purple streaks associated with clubbing. Pulmonary disease, or disease of the lungs, and heart diseases resulting in chronic hypoxia may cause clubbing. Paronychia is inflammation of the skin at the base of the nail, usually caused by an acute or chronic local infection. A patient with circulatory insufficiency may have distal digital infarcts, which involve breakdown of the skin beneath the nailbeds, extending to the end of the digit.

The nurse is assessing a patient's level of consciousness using a Glasgow Coma Scale (GCS). What precautions should the nurse take to ensure that the assessment is accurate? Select all that apply. A. Ensure the patient is as alert as possible. B. Monitor sensory losses. C. Perform tests in front of a family member. D. Obtain a signed, informed consent from the patient. E. Obtain the healthcare provider's approval.

Correct A, B A Glasgow Coma Scale (GCS) measures consciousness on a numerical scale based on eye, motor, and verbal response. For an accurate assessment, the nurse should ensure that the patient is alert enough to follow the instructions provided. The patient may not be able to follow instructions for the test if the patient has a sensory loss such as sight or hearing. It is not necessary to perform the test in front of a family member; it is like a short interview. The test is noninvasive; therefore, an informed consent may not be necessary. The nurse can perform the test without the orders of a healthcare provider.

During a physical examination, which area of the body should the nurse assess for cyanosis in a patient? Select all that apply. A. Mucous membranes B. Skin C. Sclera of the eye D. Nail beds E. Inside the throat

Correct A, B, D In cyanosis, deoxygenated hemoglobin increases in the body and produces a bluish discoloration of the skin and mucous membranes. For the assessment of cyanosis, the skin, nailbeds, and mucous membranes are observed. Cyanosis is not found in the sclera of the eye. The inside of the throat is not the best place to assess for cyanosis because it is the least accessible area that can reliably show bluish discoloration.

In addition to cyanotic lips and nail beds, nasal flaring, and pursed lips, what sign would indicate that a patient is suffering from cardiac or pulmonary difficulty? 1. Graying of the hair 2. Clubbing of the fingers 3. Swollen toes and ankles 4. Callus formation on heels

Correct 2. Clubbing of the fingers Clubbing of the fingers is associated with chronic lack of oxygen to the capillary beds of the fingers. Callus formation on heels, graying hair, and swollen toes and ankles are not associated with respiratory difficulty. A callus may form due to thickening of the epidermis. Graying hair is an age-related change. Swollen toes and ankles may be due to fluid retention.

The nurse is caring for a geriatric patient with knee pain who reports abdominal discomfort. The nurse is preparing the patient for an abdominal assessment. Which position would be challenging for the patient during the exam? 1. Supine position 2. Fowler's position 3. Lithotomy position 4. Dorsal recumbent position

Correct 4. Dorsal recumbent position The dorsal recumbent position helps facilitates examination of the head and neck, anterior thorax and lungs, breasts, axillae, heart, and abdomen. In this position, the patient is made to lie in a supine position with the knees flexed, which may be difficult for a patient with knee pain. The supine position is a relaxed position that is suitable for the examination of the anterior thorax and lungs, breasts, axillae, heart, and abdomen. This position may help reduce discomfort for a patient with knee pain. Fowler's position is not suitable for abdominal assessment but this position is the most relaxed position. A patient with knee pain may find this position less challenging than others. Lithotomy position is suitable for the assessment of the genital organs, but is not appropriate for an abdominal assessment.

A nurse who is conducting cardiac assessment of a patient notices a very loud thrill, which is easily palpable. How can this thrill be categorized? Record your answer using a whole number. _____ grade intensity

Correct 5 A thrill is a continuous palpable sensation and can be recorded using grades. A thrill is graded 1 if it is barely audible in a quiet room. If the thrill is clearly audible but quiet, it is graded 2. Grade 3 is given to a thrill which is moderately loud. A grade 4 thrill is loud, with a palpable thrill. Grade 5 thrill is very loud and easily palpable. Grade 6 thrill is louder and may be heard without a stethoscope. The grade 6 thrill is palpable and visible.

When auscultating a patient's heart, the nurse detects the heart sound S1 and S2. She also detects a muffling heart sound between S1 and S2. It is moderately loud and best heard with the bell of the stethoscope. What is true about this sound? Select all that apply. A. It is a systolic murmur. B. It is a diastolic murmur. C. It is a low-pitched sound. D. It is a high-pitched sound. E. It is a ventricular gallop.

Correct A, C The muffling heart sound heard is a low-pitched, systolic heart murmur, which occurs between S1 and S2. Diastolic murmurs occur between S2 and the next S1. A low-pitched murmur is best heard with the bell of the stethoscope, whereas, a high-pitched murmur is best heard with the diaphragm of the stethoscope. A ventricular gallop (S3) occurs after S 2, not between S1 and S2, when blood rushes into a stiff or dilated ventricle seen in heart failure and hypertension.

Which assessment in a patient requires the nurse to use the back of the hand? 1 Size of a body part 2. Texture of a body part 3. Position of a body part 4. Temperature of a body part

Correct 4 Temperature of a body part The nurse uses the back of his or her hand to assess the temperature of the patient. This is because the skin on the back of the hand is thinner than the skin on the palm of the hand and it is more sensitive to temperature. The nurse assesses the size and position of a body part using the palmar surfaces of the fingers and finger pads. The nurse should use his or her fingertips to assess the texture, vibration, or pulsations.

A 39-year-old obese woman gave birth to a baby through a cesarean section. The mother is advised not to leave the bed for 3 days. Which scales should be used to measure the weight of the mother? Select all that apply. A. Standing scale B. Platform scale C. Electronic scale D. Bed scale E. Chair scale

Correct D, E As the obese patient cannot stand to be weighed, bed and chair scales are used to measure her weight. Patients capable of bearing their own weight use a standing scale. All the scales can be either manual or electronic and these are not specified for a bed-ridden patient. A platform scale is a type of standing scale and is calibrated by moving the large and small scales to zero.

While doing an initial inspection on a patient with subacute bacterial endocarditis, what changes would the nurse expect to find on the patient's nails? 1. Softening of the nail bed 2. Concave curves on the nails 3. Transverse depressions in the nails 4. Red or brown linear streaks in the nail bed

4. Red or brown linear streaks in the nail bed Red or brown linear streaks in the nail bed is observed in the case of the subacute bacterial endocarditis. Softening of the nail bed occurs in cases in which there is a chronic lack of oxygen. Concave curves on the nails indicate iron deficiency anemia, syphilis, and an overuse of strong detergents. Transverse depressions in nails appear during a systemic illness such as severe infection and nail injury.

Using light pressure with the index and middle fingers, a nurse cannot palpate any of the patient's superficial lymph nodes. What should the nurse do next? 1. Record this finding as normal. 2. Reassess the lymph nodes using deeper pressure. 3. Ask the patient about any history of radiation therapy. 4. Notify the health care provider that x-rays of the nodes will be necessary.

Correct 1. Record this finding as normal. Superficial lymph nodes are evaluated by light palpation, but they are not normally palpable. It may be normal to find small (less than 1.0 cm), mobile, firm, nontender nodes. Applying deeper pressure may not help in palpating superficial lymph nodes. A history of radiation therapy does not affect lymph nodes. Deep lymph nodes are detected radiographically.

A nurse grasps a fold of skin over the sternum and then gently releases. The patient's skin stays pinched. What should this indicate to the nurse? 1. The patient is dehydrated. 2. The patient is overhydrated. 3. The patient is well hydrated. 4. The patient is excessively hydrated.

Correct 1. The patient is dehydrated. When skin turgor is poor, the skin will stay pinched or will return to its original state more slowly. Decreased skin turgor is a sign of dehydration that occurs in cases of moderate to severe dehydration. Skin that is well hydrated and free of underlying disease lifts easily and returns without delay to its original position. Overhydration or excessive hydration can lead to edema (buildup of fluid in underlying tissues), not poor skin turgor.

Turgor is related to the elasticity of the skin. What is the effect on the skin when a patient has poor turgor? 1. The skin stays pinched. 2. The skin has an edematous area. 3. The skin has ruby red papules. 4. The skin falls immediately back to its original position.

Correct 1. The skin stays pinched. In poor turgor, the skin stays pinched. An edematous area is observed in the case of skin edema. Ruby red papules on the skin indicate skin lesions. The normal skin falls immediately back to its original position.

During a musculoskeletal examination, the nurse observes that the patient has kyphosis. Which assessment finding supports this condition? 1. S-shaped curvature of the spine 2. Outward curvature of the thoracic spine 3, Symmetrical aligned spine with some gentle curvature 4. Increased lumbar curvature just above the buttocks area

Correct 2. Outward curvature of the thoracic spine Kyphosis is an outward curvature of the thoracic spine. Scoliosis is a sideways or S-shaped curvature of the spine and is always abnormal. A normal spine should be aligned, with some gentle curving. The body should normally appear symmetrical when compared side-to-side. Lordosis is a condition that causes an increased lumbar curvature just above the buttocks area.

While assessing the adult patient's lungs, the nurse identifies the following assessment findings. Which finding should be reported to the health care provider? 1. Respiratory rate: 14 2. Pain reported when palpating posterior lower thorax 3. Thorax rising and falling symmetrically for right and left lungs 4. Vesicular breath sounds heard with auscultation of peripheral lung fields

Correct 2. Pain reported when palpating posterior lower thorax Any areas of tenderness or pain over the posterior thorax could indicate injury such as a broken rib or disturbance of the integumentary system. Further palpation should be avoided until more assessment data are collected, either through further health history or diagnostic testing. All other findings are normal.

Jaundice produces a yellow-orange discoloration of body tissues. Which body part is the best site for the nurse to inspect for jaundice? 1. Lips 2. Sclera 3. Mouth 4. Tongue

Correct 2. Sclera The best site to inspect for signs and symptoms of jaundice is the sclera, or the mucous membranes. Inspection of the lips, mouth, and tongue is not as helpful for assessment of jaundice because discoloration of these structures occur relatively late in the disease process.

A patient reports abdominal pain to the nurse. How should the nurse examine the organs in the abdomen to evaluate the patient's condition? 1. The nurse should perform light palpation with the pad of the fingers. 2. The nurse should palpate the abdomen by applying deep pressure with one or both hands. 3. The nurse should apply mild pressure with the dorsum of the hand over the abdomen. 4. The nurse should grasp the skin over the abdomen with the fingertips.

Correct 2. The nurse should palpate the abdomen by applying deep pressure with one or both hands. The nurse can examine the condition of the organs in the abdomen using deep palpation. In deep palpation, the area under examination is depressed approximately 4 cm by using one hand or both hands. Light palpation is used to examine superficial areas of tenderness. The dorsum of the hand is used to examine temperature, moisture, and texture rather than the internal organs. Grasping with the fingertips is used to examine turgor and elasticity, tenderness, and thickness of the skin.

Which of the following physical examination techniques are most helpful when assessing a patient? Select all that apply. A. Palpation B. Evaluation C. Percussion D.Visualization E. Auscultation

A, C, E Palpation, percussion, and auscultation are all techniques the nurse uses during a physical examination. Palpation refers to assessing by touch. Percussion involves assessment by tapping the skin with the fingertips to vibrate underlying tissues and organs. Auscultation involves listening to body sounds to detect variations from normal functioning. Evaluation and visualization are not formal techniques of physical examination.

A nurse is assessing a patient's skin for lesions. Which are examples of primary skin lesions? Select all that apply. A. Scars B. Warts C. Petechiae D. Insect bites E. Pressure ulcers

B, C, D Skin lesions are of two types, namely, primary skin lesions and secondary skin lesions. Primary skin lesions arise from the normal skin and include warts, petechiae, and insect bites. Warts are solid, raised lesion with distinct borders. Petechiae are a result of hemorrhage under the skin. Insect bites are the primary skin lesions that occur due to the bite of an insect. Secondary skin lesions are the lesions that occur due to some changes in primary lesions. Examples of secondary skin lesions include scars and pressure ulcers.

A nurse is assessing a patient's heart and lungs. Which positions are usually recommended for this? Select all that apply. A. Prone position B. Lithotomy position C, Sitting position D. Lateral recumbent position E. Sims' position

Correct C, D In the sitting position, it is easy to examine the anterior and posterior thorax, lungs, heart, and vital signs. This is because sitting provides full expansion of lungs and better visualization of symmetry of upper body parts. The lateral recumbent position is useful in detecting heart murmurs. The prone position is generally used for the assessment of the musculoskeletal system. The lithotomy position is used for examining the female genitalia and genital tract. The Sims' position is for the examination of the rectum.

A patient is admitted to the hospital with an intestinal obstruction. A surgical nurse records the vitals and starts to examine the abdomen of the patient. In which order should the nurse conduct the examination? Arrange the activities in the correct order. 1. Inspection of abdomen 2. Consent from the patient 3. Auscultation of abdomen 4. Palpation of abdomen

Consent from the patient Inspection of abdomen Auscultation of abdomen Palpation of abdomen The nurse has to receive consent before performing any procedure on a patient. It is recommended that the nurse take a clinical history and do the physical examination of the abdomen afterward. Auscultation of abdomen should be done before palpation during the abdominal assessment because manipulation of the abdomen alters the frequency and intensity of bowel sounds. The best time to auscultate is between meals. Absent sounds indicate a lack of peristalsis, possibly the result of bowel obstruction (late stage), paralytic ileus, or peritonitis.

Which sound can be heard only at the base of the lung during auscultation? 1.Crackles 2. Rhonchi 3.Wheezes 4. Pleural friction rub

Correct 1. Crackles Crackles, rhonchi, wheezes, and pleural friction rub are all adventitious lung sounds. Crackles are heard at the base of the lung during auscultation. Rhonchi are sounds heard over the trachea and bronchi. Wheezes are heard over all lung fields, not just at the base of the lung. Pleural friction rub is heard over the anterolateral lung field.

The nurse inspects a patient's nails and finds that the nails have concave curves. What could the nurse infer from this observation? 1. The patient's nails are normal. 2. The patient has anemia. 3. The patient has a nail injury. 4. The patient has a local infection.

Correct 2. The Patient has anemia The condition of the nails reflects the overall health and nutrition of an individual. Concave curves on the nails are not a normal finding and indicates that the patient has anemia. In nail injury, transverse depressions, or Beau's lines, may be observed in the nails. Inflammation of the skin at the base of the nail indicates a local infection and is referred to as paronychia.

A nurse is performing a physical examination of a patient. What finding would favor the diagnosis of arterial insufficiency? 1. Marked edema 2. Rise in local temperature 3. Diminished or absent pulses 4. Pale skin color which improves on elevation of extremity

Correct 3. Diminished or absent pulses Diminished or absent pulses occur in arterial insufficiency as there is inadequate blood supply to the peripheral circulation. There is little to no edema in arterial insufficiency, while marked edema is seen in venous insufficiency. There may be local coolness on the affected area in arterial insufficiency. The skin is pale but it worsens on elevation of the extremity in arterial insufficiency.

A nurse is examining a patient in the examination room. At what angle should the nurse elevate the head of the examination table so that the patient is comfortable? Record your answer using a whole number. _______ degrees

Correct 30 degrees. While performing an examination of the patient's head, the table should be elevated at an angle of 30 degrees. This inclined position is most comfortable for the patient's head and neck and is also suitable for the assessment.

A patient is admitted to the hospital with cirrhosis of the liver. A nurse performs a physical assessment on the patient. Which body areas should the nurse inspect for jaundice? Select all that apply. A. Sclera B. Hard palate C Ankles D. Tip of the nose E. Feet

Correct A, B Jaundice is a yellow hue to the skin, mucous membranes, or eyes of both light- and dark-skinned individuals. The yellow pigment results from excess bilirubin, a by-product of red blood cell destruction, or liver failure. The best place to evaluate a patient for jaundice is the sclera or, on darker-skinned individuals, the hard palate. The tip of the nose and the ankles and feet may not show bilirubin deposition.

A patient comes to a clinic for regular checkup. A nurse is performing a physical examination of the patient. What interventions should the nurse follow during inspection to get the best results? Select all that apply. A. Make sure that adequate lighting is available. B. Use a penlight or lamp to inspect body cavities. C. Inspect each area for size, shape, color, symmetry, position, and abnormality. D. Expose the patient completely for an easy inspection. E. Check for side-to-side symmetry.

Correct A, B, C, E To get the best results from inspection, there should be adequate lighting for easy viewing. A penlight or lamp should be used for inspecting body cavities. An indirect source may not help in the visualization of inside of the body cavity. Each area should be inspected for size, shape, color, symmetry, position, and abnormality to detect any changes. Checking for side-to-side symmetry ensures that the inspected area has no deviation. The patient should not be completely exposed. Expose body parts only as needed to maintain privacy.

During the assessment of a patient, the nurse palpates the abdomen lightly. What is the nurse trying to assess in the patient? Select all that apply. A. Presence of hernia B. Muscle integrity of the abdomen C. Presence of an intestinal infection D. Rebound tenderness of the abdomen E. Presence of urinary bladder distention

Correct A, B, E Palpating the abdomen lightly helps to assess the presence of hernias, muscle integrity of the abdomen, and bladder distention in the patient. Light palpation is sufficient to assess the presence of hernias and bladder distention, as these involve the protrusion of an organ or distention of the abdomen. Light palpation of the abdomen does not help to assess the presence of intestinal infections. Rebound tenderness is the pain that occurs in the patient after palpating an abdominal area. The nurse cannot assess rebound tenderness by palpating the abdomen lightly. Assessment of rebound tenderness of the abdomen needs deep palpation. The nurse palpates the abdomen for rebound tenderness to help determine if appendicitis is present.

A nurse has to position a patient in the lithotomy position. Which statement about the lithotomy position is true? Select all that apply. A. This position helps in detecting murmurs. B. This position facilitates insertion of vaginal speculum. C. This position is adopted for examination of female genitalia. D. The patient is laid down laterally with flexion of hip and knee. E. The patient is laid down supine, the legs are raised, and knees flexed.

Correct B, C, E The lithotomy position is the best position for facilitating insertion of a vaginal speculum. It gives maximum exposure of the female genitalia and is useful in gynecological procedures. The patient is made to lie supine and her legs are raised and flexed at the knee. This position doesn't help in detecting murmurs. Murmurs are best heard in the lateral recumbent position. The patient is made to lie laterally with flexion of hip and knee in Sim's position.

A healthcare provider is testing pupillary reflexes in an adult patient. When the healthcare provider shines the penlight into the right eye, the nurse observes constriction of the left pupil but no constriction of the right pupil. When a distant object is brought closer to the patient, his left eye converges and its pupil constricts but the right eye fails to constrict. What does this indicate? Select all that apply. A. Consensual light reflex of the left eye is positive. B. Direct light reflex of the right eye is negative. C. Direct light reflex of the right eye is positive. D. Accommodation is present in the right eye. E. Accommodation is present in the left eye.

Correct A, B, E Pupillary reflexes are tested in a dimly lit room. When the penlight is shined on the pupil of one eye, the pupil constricts, and the opposite pupil constricts consensually. To test for accommodation, the patient is asked to gaze at a distant object and then at a test object held 10 cm in front of the patient's nose. The pupils normally converge and accommodate by constricting when looking at close objects. Therefore in this case, consensual light reflex of the left eye is positive, direct light reflex of the right eye is negative, and accommodation is present in the left eye only.

A public health nurse is conducting a health camp in a remote rural area. She has assessed the skin turgor of all patients as part of a total health checkup. How do certain conditions affect skin turgor? Select all that apply. A. Age is indirectly proportional to skin turgor. B. Body fluid levels regulate skin turgor. C. Dehydration decreases skin turgor. D. Edema increases skin turgor. E. The most reliable site for assessment of skin turgor is the back of the hand.

Correct A, B,C Normally the skin loses its elasticity with age. Age is indirectly proportional to skin turgor; as age increases, skin turgor decreases. Fluid balance can also affect skin turgor. Skin turgor is directly proportional to body fluid; loss of body fluid decreases skin turgor. Turgor is decreased by dehydration. Presence of edema decreases skin turgor. Turgor cannot be reliably assessed on the back of the hand, because the skin there is normally loose and thin. Skin on the back of the forearm or sternal area is used for the assessment of skin turgor.

When auscultating a patient's heart, the nurse detects the heart sound S1 and S2. She also detects a muffling heart sound between S1 and S2. It is moderately loud and best heard with the bell of the stethoscope. What is true about this sound? Select all that apply. A. It is a systolic murmur. B. It is a diastolic murmur. C. It is a low-pitched sound. D. It is a high-pitched sound. E. It is a ventricular gallop.

Correct A, C The muffling heart sound heard is a low-pitched, systolic heart murmur, which occurs between S1 and S2. Diastolic murmurs occur between S2 and the next S1. A low-pitched murmur is best heard with the bell of the stethoscope, whereas, a high-pitched murmur is best heard with the diaphragm of the stethoscope. A ventricular gallop (S3) occurs after S 2, not between S1 and S2, when blood rushes into a stiff or dilated ventricle seen in heart failure and hypertension

The nurse is planning to teach the student nurse how to assess the hydration status of an older adult. Which techniques are appropriate for this situation? Select all that apply. A. Inspect the lips and mucous membranes to determine if they are moist. B. Pinch the skin on the back of the hand to see if the skin tents. C. Check the patient's pulse and blood pressure. D. Weigh the patient daily. E.Palpate the patient's skin lightly to determine texture.

Correct A, C, D By assessing for moisture of the mucous membranes and lips, the nurse can quickly evaluate the patient's hydration status. Weighing a patient shows increases of fluid volume from day to day that could result from cardiac problems. This provides useful information about fluid status over time. Blood pressure can indicate fluid status, but be aware it also can be related to other diseases. Skin on older individuals loses its elasticity, and assessing skin on the dorsum of the hand provides inaccurate data regarding skin turgor.

The nurse is teaching a patient with poor arterial circulation about checking blood flow in the legs. Which information should the nurse include? Select all that apply. A. A normal pulse on the top of the foot indicates adequate blood flow to the foot. B. To locate the dorsalis pedis pulse, take the fingers and palpate behind the knee C. When there is poor arterial blood flow, the leg is generally warm to the touch. D. Loss of hair on the lower leg indicates a long-term problem with arterial blood flow. E. Long periods of sitting or standing may help increase blood flow.

Correct A,D A normal dorsalis pedis indicates good arterial blood flow to the lower extremities. Chronic loss of arterial flow results in a lack of hair growth and the appearance of shiny tissue. The dorsalis pedis is located along the top of the foot between the great toe and first toe. When there is poor arterial flow, the skin will be cool.

The nurse documents that a hospitalized patient is alert and oriented × 2. Which findings in the patient enabled the nurse to make such conclusions? Select all that apply. A. The patient has the ability to interpret idioms. B. The patient has difficulty recalling the current date. C. The patient is able to say the name of the hospital. D. The patient is able to recollect the events of the past. E. The patient is unable to recognize family members.

Correct B, C In some cases, hospitalized patients may have difficulty recalling the current date or time but remain completely oriented to person and place, making them alert and oriented × 2. When the patient is able to tell the name of the hospital, the patient is oriented toward the place. If a patient is having difficulty recalling the current date, the patient is having difficulty in distinguishing date. A patient who is unable to distinguish time and date may not be able to recollect events of the past. A patient who is alert and oriented × 2 is oriented toward person and place. Therefore, this patient can identify family members. To assess abstract thinking and higher-level cognitive functions ask the patient to interpret idioms. This does not assess levels of orientation.

A patient is brought to the emergency room following a motor vehicle accident. The nurse assesses the patient's levels of consciousness using a Glasgow Coma Scale (GCS). What parameters does this test evaluate? Select all that apply A. Lateralization of sound B. Opening of eyes C. Verbal response D. Motor response E. Air and bone conduction

Correct B, C, D The parameters tested in Glasgow Coma Scale (GCS) include opening of eyes in response to commands, verbal responses, and motor response to commands. A fully conscious patient responds to questions quickly and expresses ideas logically. The lateralization of sound is assessed by Weber's test. Air and bone conduction in the ears is assessed by the Rinne test.

The parent of a child reports to the nurse, "My son has had stomach pain for the past several days." The nurse palpates the abdomen of the child and finds it to be rigid. Which conditions does the nurse monitor the child for based upon this finding? Select all that apply. A. Hernia B. Ascites C. Appendicitis D. Acute cholecystitis E. Peritoneal inflammation

Correct C, D, E Palpation is the technique of using the hands to examine the physical status of a patient. Rigidity of the abdomen results from inflammation in the underlying tissues, occurring in conditions such as appendicitis, acute cholecystitis, and peritoneal inflammation. A hernia does not involve inflammation of the abdominal tissues and therefore does not cause abdominal rigidity but can cause visible protrusion or bulges. A wavelike sensation during abdominal palpation indicates ascites.

A patient is admitted to the hospital with cirrhosis of the liver. A nurse performs a physical assessment of the patient. Which area of the hand should the nurse use when palpating the liver? Select all that apply. A. Dorsum of the hand B. Ulnar surface of the entire hand C. Pads of fingers D. Entire palmar surface of the hand E. Palmar surface of the fingers

Correct D, E The nurse should use the entire palmar surface of the hand or the palmar surface of the fingers to palpate the liver. These surfaces of the hand are more sensitive and are used to determine the size, shape, tenderness, and absence of masses in the liver. The dorsum of the hand is used to assess temperature. The ulnar surface of the entire hand is used to assess fremitus. The pads of fingers are used to assess the glands.

During the skin assessment of a patient, the nurse observes that the skin lifts easily and falls immediately back to its resting position. What should the nurse interpret from this assessment? 1. It is a normal skin finding. 2 It indicates dehydration. 3. It indicates pitting edema. 4. It indicates lost skin vascularity.

Correct 1. It is a normal skin finding. If the skin is lifted and falls back immediately, this indicates a normal skin finding. This test is used to assess the elasticity or the turgor of the skin. In case of dehydration, the skin fails to reassume its normal contour or shape after the skin is lifted and released. When pressure from the examiner's fingers leaves an indentation in the edematous area, it is called pitting edema. Loss of skin vascularity may be evident through pale skin.

The nurse is assessing the skin of a patient with anemia and finds that the facial skin, nailbeds, and palms of the hands have decreased skin tone. Which assessment finding does the nurse anticipate in the patient? 1. Pallor 2. Vitiligo 3. Purpura 4. Erythema

Correct 1. Pallor Decreased skin tone on the face, nailbeds, and palms indicates pallor in the patient. Pallor is a manifestation of anemia. Vitiligo refers to the loss of pigment on the hands, face, and genital areas. Decreased skin tone does not occur in patients with vitiligo. Purpura (bleeding underneath the sin) refers to a red pigmentation of the skin that does not blanch when pressure is applied. Purpura is not associated with decreased skin tone. Erythema is redness of the skin caused by congestion or dilation of the superficial blood vessels in the skin, signaling circulatory changes to an area.

After assessing a patient the nurse determines that Beau's lines are present. Which finding in the patient enabled the nurse to make such a conclusion? 1. Transverse ridging in the nails 2. Double band of white lines in the nails 3. Stretch marks over the abdomen 4. Symmetrical swelling of the abdomen

Correct 1. Transverse ridging in the nails A temporary gap in the nail growth of a person may cause transverse ridging in the nails, called Beau's lines. These lines occur in conditions such as eczema, psoriasis, and paronychia. Renal disease can cause double band of white lines, termed Muehrcke's lines. Striae are stretch marks on the abdomen resulting from pregnancy and weight loss or gain. Symmetrical swelling of the abdomen, also known as distention, occurs when intestinal gas (flatus), excess fluid, or a tumor is present in the abdominal cavity.

A nurse is auscultating a patient's breath sounds. A nurse hears low, soft, blowing normal breath sounds over most of the lung fields. How should the nurse chart this finding? 1. Vesicular breath sounds present. 2. Bronchial breath sounds present. 3. Diminished breath sounds present. 4. Adventitious breath sounds present.

Correct 1. Vesicular breath sounds present. Low, blowing, soft normal breath sounds heard over most of the lung fields are vesicular breath sounds. High, hollow, loud normal breath sounds heard over the main stem bronchi are bronchial breath sounds. Abnormal breath sounds that originate in the lungs and airways are referred to as adventitious breath sounds. Diminished breath sounds are abnormal and occur if the patient has atelectasis (collapse of all or part of the lung).

A nurse is performing a physical examination on a patient. Where should the nurse palpate for the apical impulse? 1. At the second intercostal space on the right side 2. At the fourth intercostal space just medial to the left midclavicular line 3. At the fourth or fifth intercostal space along the sternum 4. At the left sternal border to the third intercostal space

Correct 2. At the fourth intercostal space just medial to the left midclavicular line. The apex of the heart touches the fourth to fifth intercostal space just medial to the left midclavicular line; the apical impulse is palpated best in this anatomical region. The second intercostal space on the right side is the aortic area. The fourth or fifth intercostal space along the sternum is the tricuspid area. The second pulmonic area is at the left sternal border to the third intercostal space.

A nurse is preparing to perform a physical examination on a patient. What nursing action is most appropriate when preparing to examine a patient? 1. To fill out the consent form before physical examination 2. To maintain the appropriate room temperature 3. To perform the physical examination in the radiology unit 4. To ask the patient's family members to sit beside the patient

Correct 2. To maintain the appropriate room temperature While performing the physical examination, maintaining appropriate room temperature is an important step. A very warm temperature causes vasodilation resulting in increased redness of the skin. In a very cool environment, a sensitive patient may develop cyanosis around the lips and nail beds. A consent form is not required for a physical examination. A physical exam should be performed in the examination room or the emergency room rather than the radiology unit. The patient requires privacy during the physical examination; therefore, family members are not always allowed to sit beside the patient.

Using the Glasgow Coma Scale, what would be the score of a patient who is in a deep coma? 1. 0 2. 1 3. 3 4. 10

Correct 3. 3 The Glasgow Coma Scale ranges from the lowest score of 3 to the highest score of 15. A score of 3 would indicate that the patient is in the deepest coma. A score of 0 or 1 is incorrect because these numbers are lower than the number at which the scale begins measurement. A score of 10 would indicate higher cognitive functioning.

A patient developed a hernia after a surgery. What is the most probable reason for this complication? 1. Prostatectomy 2 Lobectomy of the lung 3. Abdominal surgery 4. Removal of meningioma

Correct 3. Abdominal surgery A hernia is a complication of abdominal surgery. The other complications of abdominal surgery include intestinal obstruction and altered bowel function. Prostatectomy has complications of urinary incontinence, sexual dysfunction, and poor body image. Complications of lung resection or lobectomy of the lung include difficulty breathing, fatigue, and generalized weakness. Surgery involving the brain or spinal cord such as removal of meningioma has a risk of impaired cognitive function, motor sensory alterations, altered vision, as well as swallowing, language, bowel, and bladder control issues.

A patient found unresponsive, now opens eyes when spoken to, gives correct answers to the simple questions when asked, and usually sleeps when left unattended. Which category of the Glasgow Coma Scale has the nurse assessed? 1. Eye opening and motor activity 2, Motor activity and motor response 3. Eye opening and best verbal response 4. Best verbal response and best motor response

Correct 3. Eye opening and best verbal response The Glasgow Coma Scale requires a nurse to use three score ranges based on the categories of eye opening, verbal responsiveness, and motor response. In this case, the nurse's assessment reflects eye and verbal response only. No motor activity, such as the ability of the patient to follow commands or spontaneous movement by the patient, is noted.

While assessing the skin of a patient, the nurse finds a brown and flat lesion that has irregular borders with undefined margins. The nurse also finds variegated pigmentation with poor margins on the patient's skin. Which condition does the nurse anticipate in the patient? 1. Cerumen 2. Petechiae 3. Melanoma 4. Borborygmi

Correct 3. Melanoma The notched border of the lesion and irregular shape with brown color indicate the presence of melanoma in the patient. Variegated pigmentation is a manifestation of melanoma in the patient. Cerumen is a small amount of earwax, which may be yellow to dark brown in appearance. Petechiae are characterized by the presence of tiny dark red spots that indicate hemorrhage below the skin. If the intestinal tract is overstimulated or has increased motility, hyperactive bowel sounds, known as borborygmi, are heard as a loud grumbling.

While auscultating the patient's heartbeat, the nurse finds a loud murmur with a palpable thrill. How does the nurse classify this finding? 1. Grade 1 2. Grade 2 3. Grade 3 4. Grade 4

Correct 4. Grade 4 The nurse grades the murmur according to its intensity. The nurse classifies a loud murmur with palpable thrill as a grade 4 cardiac murmur. A barely heard cardiac murmur in a quiet room is classified as grade 1. Quiet but readily heard sounds with the aid of a stethoscope are grouped under grade 2 of cardiac murmurs. Easily heard sounds with a stethoscope are classified as grade 3 cardiac murmurs.

The nurse is assessing a patient who returned 3 hours ago from a cardiac catheterization, during which the large catheter was inserted into the patient's femoral artery in the right groin. Which assessment finding would require immediate follow-up? 1. Palpation of a femoral pulse with a heart rate of 76 2. Auscultation of a heart murmur over the left thorax 3. Identification of mild bruising at the catheter insertion site 4. Palpation of a right dorsalis pedis pulse with strength of +1

Correct 4. Palpation of a right dorsalis pedis pulse with strength of +1 A weak pulse may indicate disruption of arterial flow and should be reported immediately. Mild bruising is normal, but if it increases in size, the femoral artery may be leaking, requiring further follow-up with the health care provider. Other findings are within normal limits and do not require notification.

While assessing a patient with renal disease, the nurse finds a double band of white lines on the nails. How should the nurse interpret this assessment finding? 1. The patient has paronychia. 2. The patient has koilonychias. 3. The patient has Beau's lines. 4. The patient has Muehrcke's lines.

Correct 4. The patient has Muehrcke's lines. A double band of white lines, or leukonychia, on the nails of an individual indicates Muehrcke's lines. These lines generally occur in the patient with renal disease. Paronychia manifests as inflammation at the base of the nailbed due to local infection. Paronychia is not associated with renal disease. Koilonychia involves the concave curvature of the nails. It occurs in patients with iron-deficiency anemia or syphilis. Transverse ridging in the nails indicates Beau's lines and can occur in patients with eczema, psoriasis or nail injury.

The nurse is teaching a nursing student about the various deformities of the spine. Which statements are true about spine deformities? Select all that apply. A. Scoliosis is the medial deviation and plantar flexion of the foot. B. Kyphosis is the increased convexity in curvature of thoracic spine. C. Kyphosis is the internal rotation of forefoot or entire foot. D. Lordosis is the exaggeration of anterior convex curve of lumbar spine. E. Scoliosis is a lateral S- or C-shaped spinal column with vertebral rotation.

Correct B, D, E Kyphosis is the increased convexity in curvature of thoracic spine. It may be caused by rickets, osteoporosis, or tuberculosis of the spine. Lordosis is the exaggeration of anterior convex curve of lumbar spine. This can be a congenital condition or a temporary condition as in the case of pregnancy. Scoliosis is a lateral S- or C-shaped spinal column with vertebral rotation. This can be a consequence of numerous congenital, connective tissue, and neuromuscular disorders. The medial deviation and plantar flexion of the foot is called clubfoot, and is not a spinal deformity. The internal rotation of forefoot or entire foot is called pigeon toes, and it is not a spine deformity.

The nurse is planning a staff education conference about abdominal assessment. Which point is important for the nurse to include? 1. The aorta can be felt using deep palpation in the upper abdomen near the midline. 2. The patient should be sitting to best determine the contour and shape of the abdomen. 3. Always palpate the abdomen before performing auscultation. 4. Avoid palpating the abdomen if the patient reports any discomfort or feelings of fullness.

Correct 1 The aorta can be felt using deep palpation in the upper abdomen near the midline. Anatomically the aorta is located in the upper abdomen and can be palpated on an average-sized patient. Complete abdominal assessment includes inspection, followed by auscultation, palpation, and percussion (if warranted). The assessment should be performed when the patient is supine so all assessment techniques can be included. Palpation should be performed routinely, but leave areas of discomfort or pain until last.

A nurse finds that a patient with a congenital heart disease has clubbing. What is the reason for clubbing in the patient? 1. It is a disorder of the nail. 2. It is due to insufficient oxygenation at the periphery. 3. It is a condition that runs in families. 4. It is secondary to neurological damage due to heart disease.

Correct 2 It is due to insufficient oxygenation at the periphery. Clubbing refers to the bulging of tissue at the nail bed. It is caused due to insufficient oxygenation in the extremities due to a chronic lung disorder or congenital heart diseases. It is caused by inadequate oxygenation and is not a disorder of the nail. Clubbing does not run in families. Clubbing does not involve any neurological damage.

A nurse is performing a physical examination on a patient. What position is the most suitable for an abdominal examination? 1. A Sim's position 2. A lithotomy position 3. A sitting position 4. A dorsal recumbent position

Correct 4 A dorsal recumbent position The dorsal recumbent position is best suited for an abdominal examination. In this position, the abdominal muscles are relaxed and the examiner has full access to the abdomen. A Sim's position is best suited for examination of the rectum and vagina. A lithotomy position is best suited for examination of the female genitals. The sitting position helps in examination of head and neck and the chest.

A patient comes to the clinic for regular checkup. A nurse is performing a physical examination on the patient. Which intervention should the nurse perform when performing palpation? 1. Palpate the tender areas first. 2. Ask the patient to take shallow breaths. 3. Instruct the patient to keep both hands on the abdomen. 4.Warm the hands and use a gentle approach.

Correct 4 Warm the hands and use a gentle approach. The nurse should perform palpation by warming hands and using a gentle approach. Cold hands can cause the muscle to contract and interfere with palpation. The tender areas should be palpated last as it is painful for the patient. The patient should be instructed to take deep breaths. It helps the patient to relax. The patient should keep the hands on the sides to prevent interference with the palpation.

The nurse plans to assess the patient's abstract reasoning. Which task should the nurse ask the patient to perform? 1. "Tell me where you are." 2. "What can you tell me about your illness?" 3. "Repeat these numbers back to me: 7...5...8." 4. "What does this mean: 'A stitch in time saves nine?'"

Correct 4. "What does this mean: 'A stitch in time saves nine?'" Abstract reasoning requires cognitive functioning and the ability to identify relationships between concepts.

While assessing the level of consciousness in a patient, the nurse finds that the patient opens the eye only when there is a pain stimulus, gives inappropriate responses, and has a decorticate posture. What is the score of the patient on the Glasgow coma scale? Record your answer using a whole number. Answer: ____________

Correct Answer 8 The Glasgow coma scale helps to assess the level of unconsciousness in a patient. When the patient opens the eyes only during pain stimulation, the score for eye opening will be 2. The score for inappropriate verbal responses is 3. The score for decorticate posture on the Glasgow coma scale is 3. Therefore, the total score of the patient on the Glasgow coma scale will be 2+3+3 = 8.